ANICOLAU.RO. Enhanced Recovery after Colorectal Surgery. Irina Grecu, Alexandru E. Nicolau, Olle Ljungqvist*

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1 Enhanced Recovery after Colorectal Surgery Irina Grecu, Alexandru E. Nicolau, Olle Ljungqvist* Clinical Emergency Hospital of Bucharest, Romania *Karolinska Institute, Stockholm, Sweden

2 ERAS - Enhanced Recovery After Surgery Rationale: supporting wound healing and recovery by: reducing the stress of surgery, minimizing catabolism and promoting anabolism. Denmark (Hvidovre University Hospital, Copenhagen) Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78(5): median LOS 2 and 4 days after colonic and rectal surgery (Basse et al. Ann Surg 2000;23(1): ERAS multicentre trial: Copenhagen, Edinburgh, Stockholm, Tromsø, Maastricht Nygren J et al. Clinical Nutrition 2005; 24:

3 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

4 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

5 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

6 Mechanical Bowel Preparation (MBP) Dehydration before surgery Overnight fasting - further dehydration Increased risk for hypotension during anesthesia Increased risk for excess fluid treatment Gut oedema - paralysis Holte K, Dis Colon Rectum 2004; 47,

7 MBP Not necessary has no benefit in colorectal surgery Slim K et al. J. Br J Surg 2004 Wille-Jorgensen P et al. Dis Colon Rectum 2003 Platell C, Hall J. Dis Colon Rectum 1998 Pineda CE et al. J Gastrointest Surg 2008 Gravante G et al. Int J Colorectal Surg 2008 Harmful! Dehydration/electrolyte abnormalities (elderly!) Patient discomfort May increase risk for anastomotic leak! Slim K, Vicaut E, Panis Y, Chipponi J. Br J Surg 2004;91(9):

8 MBP risk for anastomotic leak N = 1454, OR 1.75 ( ), p = Slim K et al BJS 2004; 91,

9 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

10 Preoperative CHO drink or How to Make Everybody Happy Oral CHO drink (12.5%), 800 ml the night before and 200 ml 2 hs preop preop anxiolysis postop insulin resistance fastens recovery PONV after laparoscopic cholecystectomy Nygren et al. Curr Opin Clin Nutr Metab Care 2001; Hausel et al. Clin Nutr 2004

11 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

12 Prophylactic Nasogastric Decompression Following Abdominal Surgery Meta-analysis 33 Studies, N = 5,240 patients Patients without routine NG tube use had: Earlier return of bowel function (P < ) pulmonary complications (P = 0.01) LOS No difference in anastomotic leak between patients with vs without NG tubes (P = 0.70) Routine nasogastric decompression does not accomplish any of its intended goals and should be abandoned in favor of selective use of the nasogastric tube [Nelson R, et al. Cochrane Database Syst Rev. 2007;Jul 18;(3):CD004929]

13 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

14 Epidural Analgesia Mid-thoracic (T7-T8) analgesia + sympathetic block early mobilisation postop. ileus duration Preemptive analgesia/combined GE+TE stress hormones and insulin resistance postop. morbidity and mortality Rodgers A, Kehlet H et al. Br Med J 2000; 321:1493. Local anesthetics ± low dose fentanyl Avoids intra-and postop. opioids

15 TEA & Postoperative ileus Jorgensen Jorgensen Cochr Cochr Database Database Syst Syst Rev Rev

16 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

17 Hypotermia Sympathetic stimulation, acidosis, coagulation abnormalities Heating cover + warming iv fluids transfusion requirements wound infections cardiac complications Kurz A, Sessler DI, Lenhardt R. N Engl J Med 1996; 334: Frank SM et al. J Am Med Assoc 1997; 277: Schmied H et al. Lancet 1996; 347:

18 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

19 Perioperative Fluid Management Tambraya AL et al. World J Surg 2004; 28: Lobo DN et al. Lancet 2002; 359: Brandstrup B et al. Ann Surg 2003; 238: Na/fluid overload postoperative ileus, complications and LOS wet is best Avoid bowel preparation Allow CHO drink Intra-and postoperative restriction (Na <145 meq/day) Maintain 0 fluid balance low dose vasopressors if needed

20 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

21 Postoperative Oral Intake insulin resistance: preop CHO drink + TE + early oral intake starting 4 hours after surgery 400 ml energy dense oral supplements starting day 0

22 Audit of compliance/outcomes Preadmission counselling No bowel prep Early oral nutrition Early mobilisation Laxatives ERAS Preop CHO drink No NG tubes Mid-thoracic epidural Short acting anesthetic agent PONV Hypotermia No opioids, NSAIDS Short incisions, no drains Avoid periop Na/fluid overload Modified from: Fearon K et al. Clinical Nutrition 2005;24: Discharge/follow-up Antibio- and thromboprophylaxis

23 Discharge / Follow-up Discharge criteria Good pain control on oral NSAIDS Oral solid food, no iv fluids required Independently mobile or same level as preop. Willing to go home Follow-up Hotline (telephone) with hospital hs Hospital visit at 7-10 days Late visit at 30 days Good cooperation with general practitioner

24 Clinical Evidence Nygren et al. Clin Nutr 2005 observational, ERAS (DK) vs traditional care (NE, UK, NO, SE) Maessen et al. Br J Surg European centers, 425 patients: first stool after 3 days, discharge after 5 days The Northern Europe study: Lassen et al. Ann Surg 2008 no guidelines for postoperative practice in many centres The Swiss study: Müller et al. Gastroenterology 2009 (156 pts, 4 university hospitals, open colonic surgery) - LOS, complications Dutch Breakthrough Project Perioperative Care Maessen et al. Clin Nutr % pts eat normal food next day after surgery Jottard et al. Clin Nutr 2009 postop nasogastric tube use from 88% to <10% pts Inclusion criteria extended malnourished patients, advanced age are no exclusion criteria for ERAS Independent predictors for complications: comorbidities (ASA 3-4), male sex and rectal surgery (Hendry et al. Br J Surg 2009) Upper GI tract surgery (Lassen et al. Ann Surg 2008) Liver resections (van Dam Br J Surg 2008) ERAS included in the ESPEN guidelines for perioperative nutrition (Braga et al. Clin Nutr 2006)

25 A comparison in five European Centers of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery Nygren J et al. Clinical Nutrition 2005; 24: n Total 451 DK 118 NL 76 NO 61 UK 87 SE 109 Cardiorespiratory (%) Surgical total (%) Anastomotic leak Infective total (%) Pneumonia Wound infections * * 3 28* 10* Total patients with complications (%) * p<0.05 vs. DK; p<0.05 vs. DK, SE, NO, UK

26 Nygren J et al. Clinical Nutrition 2005; 24: N Total 451 DK 118 NL 76 NO 61 UK 87 SE 109 Mortality n(%) 10(2) 6(5) 2(3) 1(2) 1(1) 0(0) Readmissions n(%) 49(11) 26(22) 6(8)* 10(16) 2(2)* 5(5)* Reoperations n(%) 33(7) 8(7) 7(9) 8(13) 3(3) 7(6) LOS: median (IQR) _ 2 (1) 8(6)* 7(3)* 9(6)* 7(5)* LOS: mean (SD) _ 3 (6) 12(9)* 9(9)* 12(8)* 9(5)* Total LOS: median _ 2 (3) 8(6)* 8(4)* 9(6)* 8(6)* Total LOS: mean _ 6 (11) 12(9)* 10(9)* 12(8)* 9(6)*

27 Clinical Emergency Hospital ongoing trial patients ; median age: 60 yo Type of operations - laparoscopic resections (7p) 2p right hemicolectomies for cancer (lap surgery) 5p left hemicolectomies (3 lap surgery) 6p rectosigmoidian resections (2 lap surgery) 13 predefined FT modalities Median time until the first bowel movement: 2 nd day Solid food intake 90% starting in the first operative day Complications: -anastomotic leakeage (1p) Rate of readmission: 0% Mortality: 0% -wound infection (2p)

28 Conclusions ERAS is a multimodal perioperative approach aiming at promoting recovery after major colorectal surgery ERAS is both advantageous for the patient and for the hospital ERAS LOS and possibly postoperative complications ERAS is spreading as standard of practice throughout Europe